License Activation/Affiliation


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  1. Please allow 30 calendar days after submission of this form for processing. If you have not receive acknowledgement from the Commission within 25 days please contact the Commission Office.
  2. This form is dynamic. As you fill the form out more fields will become visible and required. Please start at the top and work your way down.

Personal Information for the Licensee who is Activating and/or Affiliating

Postlicensing and/or Continuing Education for License Activation
Postlicensing Education
Activation is requested based on which option below?*
(Select one and complete the associated fields if any)
Continuing Education
Activation is requested based on which option below?*
(Select one and complete the associated fields if any)

Request Type
(Select one)*

To Be Completed By Broker-In-Charge

Authorization
(Type your name)
(Type your name)
The Broker-in-Charge signature is required. However, if the form is being completed by the Broker, the Broker can certify that they have the BIC's permission to submit this form.
Is the Broker certifying they have the BIC's permission to submit this form? *
You must complete the reCaptcha below before submitting this form*
18.117.71.213
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This form is not meant to be printed. If you have already completed the form please use the submit button at the bottom to send the form directly to the Commission.

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